Healthcare Provider Solutions

Agencies continue to report receiving Additional Development Requests from their respective Medicare Administrative Contractors (MAC). Unless your agency is one of the lucky few, you have experienced the anxiety first hand. Reviewing and organizing the requested record prior to the MAC’s review is essential to decrease the risk of denial.

Currently, the MAC must receive the requested documentation within 30 calendar days of the date documented in the ADR. According to CMS Transmittal 567, effective 4/1/15, the time frame for the MAC to receive the ADR chart to review will be increased to 45 days. Although the new time frame allows the agency more time to comply with the request, adhering to the previous 30 day requirement would certainly prevent denials due to failure to submit timely. Additionally, having a plan in place will help ease the stress, expedite the submission process, and hopefully increase the probability of full payment!

The request for review contains a list of requested documents that must be submitted. Please be cautious of submitting additional documentation. Various additional documents may support the need for skilled services, homebound status, etc. and would be appropriate to submit, but please review the documentation carefully to ensure submitting the document would be beneficial. Ensure all of the requested information is compiled and proceed to review all of the documentation as if the Medicare reviewer was reviewing.

The most recent denial reasons include Face to Face (F2F) Encounter Requirements not met, Auto denial for failure to submit records, HIPPS code change due to partial denial of therapy, documentation not supporting medical necessity and appropriate OASIS was not submitted. Please remember if the requested episode is not the Start of Care (SOC) episode, the OASIS to support the episode requested (FollowUp/Recertification) is required to be submitted. For example, the agency admitted John Smith on 7/5/14 and the ADR if for episode dates 11/2/14 – 12/31/14. The agency would be required to submit the FollowUp OASIS that was completed between 10/28/14 and 11/1/14. Do not forget to include the F2F! The F2F is normally required in an ADR regardless of episode timing.

Click here to view our Record Review Request Audit Tool.

In addition to completing a review prior to submission, the MACs have also issued the following tips:

  • Always include the ADR letter on the top of the submitted records
  • Do not highlight records. Areas of importance may be indicated by an asterisk*
  • Do not staple or bind the records
  • Do not attach sticky notes or tabs
  • Organize the record
  • Paginate the record
  • A cover letter containing information substantiated in the medical records may be submitted

Once the record has been reviewed and organized, you may submit your records via paper, CD/DVD or electronic means. If you send a CD or DVD, please send the record in a PDF or TIFF format. Create one PDF or TIFF file per record. If your submission method requires mailing, ensure you send your records to the address listed in your ADR letter. We recommend sending the records via certified mail requiring a signature upon delivery. There have been reports that agencies have experienced denials due to failure to submit the requested information although the agencies submitted the records timely. This method will provide verification that the MAC received your record.

If you elect to submit your records electronically, please follow the link below for additional information: http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/ESMD/index.html

Please see below for links to each Medicare Administrative Contractor’s website for additional information when responding to an ADR.

Palmetto Hospice ADR Checklist

Palmetto Home Health ADR Checklist

NGS Home Health ADRs

NGS Hospice ADRs

CGS ADR

Our clinical compliance team would be happy to assist with reviewing charts that have been selected for ADR reviews or answer any additional questions you may have.  Feel free to give us a call or contact us today.